SPORTS MEDICINE MAGAZINE

G

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINEFALL 2012

Fa l l S p o r t s I s s u e

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•Academy Orthopedics - 3540 Duluth Park Lane, Sui te 220Duluth, Georgia - 770.271 .9857 - www.academyorthopedics .com

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Letter from the Editor <<<

Fall not only marks the beginnings of school days and the first relief of cooler air, this sea-son also marks the opening of a yearlong of sports. Fall alone is home to a quite a number of sport seasons, possibly more than any other

time of year. Football, cheerleading, cross country, fast-pitch softball, and volleyball players jump right into action in the beginnings of August requiring most athletes to work all the way through to the early stages of winter. As a part of Gwinnett Medical Center, the Gwinnett Sports Medicine Committee is behind the GMC motto, “The Team Behind the Team.” Several of our GSMC physicians, includ-ing myself, are Team Doctor’s for many of the surrounding schools in our county. I know from personal experience that being a Team Doctor requires a timely commitment, especial-ly in the Fall. Juggling multiple sports, practices, and games can seem like a full time job in and of itself; however, proven time and again, the benefits and needs of a committed Team Doctor is vital to your team’s, athletes’, and child’s success on and off the field. Every year our athletes seem to become more talented than the last – with that talent comes a high-er level of athleticism and higher level of play. Although in-creased quality of sports is beneficial for the players, schools, and community, it can often bring higher degrees of injuries with it. By having a Team Doctor and Team Athletic Trainer on your school’s sideline you are able to insure that the best preventative measures are being taken, that on-site care is a step away, and that all injuries are being addressed by some of the top professionals in the state. Overall, Team Doctors and Athletic Trainers warrant a healthier team and the lon-gevity of a successful athletic program. Gwinnett Sports Medicine Magazine and its authors are similarly dedicated to our community. We continually strive to promote advancing knowledge in doctors, parents, and ath-letes alike. Please take the time to investigate in your schools and teams to see if a Team Doctor is available to you – and it not, I assure you it is worth advocating for one as it is a viable resource that will keep our athletes safe and game-ready.

GSMM

If you would like to submit an article or are interested in advertising opportunities in GSMM please contact Sherri Cloud atsales@bunkerdesigncollab.com or 678.907.2912

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Contributor

Kaylee RosenbergerContributing Editor

phone: 770-237-3475 ext. 113

fax: 678-689-2940krosenberger@sportsmedsouth.com

Gary A. Levengood, MD>Chief of Sports Medicine, Gwinnett Medical Center>Orthopedic and Sports Medicine Consultant to the GHSA>Founder and Owner, Sports Medicine South, LLC>Editor, Gwinnett Sports Medicine Magazine

FALL 2012Contents Page

Features

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>Editor’s Note /// Gary A. Levengood, MD /// 3>Back from the 2012 Olympic Games ///

By: Kaylee Rosenberger /// 4-5>Kinesio Tape and Injuries ///

By: Kristen Wilkey, MS, ATC, LAT, OTC /// 6>The Art and Science of Ankle Taping vs. Bracing ///

By: Eddie Knox III ATC, LAT /// 8-9>In-Season Football Strength & Conditioning Program ///

By: Gary Schofield, Jr. ATC/L, CSCS /// 10-12>Sleep Apnea and The Athlete:Treatment ///

By: Robert A. Gadlage MD FACS /// 14-15>A Closer Look at Stingers and Burners ///

By: Tuan Bui MD /// 16>Imaging of Stingers & Burners ///

By: Lance Dasher, MD /// 18-19>To Supplement or Not to Supplement? ///

By: Ann Dunaway Teh, MS, RD, LD /// 20-21

Harris Patel, PA, ATC, one of Sports Medicine South’s talented Physician As-sistants and Certified Athletic Trainers, headed to London, England for the 2012 Summer Olympic Games. As a long time member of The US Track and Field medical team, Patel embarked on his three week journey to London beginning Thursday, July 12, 2012. His stint in Europe also includ-ed travels to Monaco, France and Birmingham, England for several USA Track and Field Team training camps. Following preliminary camps, Patel headed back to London for the completion of the 2012 Olympic Games marked by his participation in the closing ceremonies.

Back from the 2012

Olympic Games

4 GSMM

The selection process to be-come a part of this elite medical squad is highly selective and requires members to have a lengthy resume exuding diverse experience and professional credentials. The process alone can be extensive and calls for applicants to “work their way up” to the higher level events over the years. Typically, ap-plicants are first required to perform a two week internship at a designated USOC facility. The internship tests a range of skills, requiring applicants’ long hours of multiple sports coverage throughout the day as well as stints in the general training rooms. The applicants are watched and judged every step during those two gruel-ing weeks, with a final evalua-tion at the end. If an applicant receives a “yes” letter for their evaluation, they are then given the opportunity to begin cov-ering USOC events, typically beginning at the Youth competi-tion level. For Patel, his journey through the USOC selection process actually began with becoming credentialed through the National Governing Board (NGB) of US Track and Field in 2002. Through the NGB, Patel covered his first Youth Championship games in 2003, and then quickly was moved to Senior level competi-tions, such as the 2007 Pan American Games, thereafter. Patel’s work ethic, diverse knowledge, and dedication to athletes at each event did not go unnoticed; in fact, it was the high recommenda-tion from the NGB that helped Patel progress through the USOC process and eventually land a spot on the USOC medical team for the 2008 Beijing Olympics.

Participating on the medical team is purely volunteer that yields little time to anything other than providing extensive medical sup-port for the athletes; however, being selected to serve is an extremely esteemed honor that few ever get to experience. As Patel says, “It is an honor to represent the USA across the world. We are dressed in red, white, and blue from head to toe, and work as a team to be exceptional American ambassadors. At any world championship, USA athletes from across the nation come together for one pur-pose and as one team – needless to say, it is in invaluable experience to be a part of.”

Patel is a regular when it comes to the world travels of the USA Track and Field Team. In fact, he traveled to Daegu, Korea for the 2011 IAAF World Outdoor Track & Field Championships just a year ago. Patel’s other world travels have included Bejing, China; Rio de Janeiro, Bra-zil; Helsinki, Finland; and Sherbroke, Canada as part of the official medical support staff for the USA T&F team. Patel, in conjunction with only a dozen or so selected medical providers, work to provide medical coverage to the 120+ track and field athletes to represent the United States in the 2012 Olympic Games. Medical coverage for the T&F Olympic competitors includes, but is not limited to, injury prevention, massage therapy, stretching, and rehabilitation. Proper medical coverage for the most elite USA athletes can lead to long and demanding days. On average, the medical staff will be working 18 to 20 hours daily – literally going straight through from dawn to mid-night. The demanding work schedule does not even allow the medical staff to witness any of the live events during their stay at the Olympic Games; however, comprehensive medical support is a main component in achieving suc-cess for both the athlete and, more importantly, for the United States team as a whole.

Back from the 2012 Olympic Games <<<

/// By: Kaylee Rosenberger

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6 GSMM

With the recent broadcast of the Olympics, we all saw a little more of the new col-orful athlete favorite, Kine-siotape. The first worldwide

exposure of this taping was actually during the1988 Seoul Olympics,but it did not become a craze in the United States until the 2008 Beijing Summer Olympics when US women’s volleyball playerKerri Walsh was seen nu-merous times with the tape following shoulder surgery. The tape itself has been around since it was officially founding in 1979by Japanese Chiropractor Dr. Kenzo Kase who wanted to create a therapeutic taping tech-nique that would support muscles, but not restrict range of motion. So with all these athletes wearing this eye catching tape, what does it do exactly? The tape is designed to run along the contours of the skin and last for three to five days eventhrough sweating and water. The spe-cifically designed elasticity of the tape is accredited to lightly lifting the skin and reducing friction between the skin and muscle as well as increasing circulation. Dr. Kaseactually attributes four major functions to theKi-nesiotape method. The first is supporting the muscle, which is done in many ways when it is applied properly. Muscle support from Kinesiotape includes improving the muscle’s ability to contract even if injured, reducing pain and fatigue and protection from cramping. Skilled practitioners may also apply the tape to improve blood and lymphatic circulation, as well as reduce inflamma-tion and excess chemical buildup in the body. Third, it is believed to activate the endogenous analgesic system, meaning that the tape facilitates the body’s own heal-ing mechanism. Lastly, by improving range of motion and adjusting malalignments that result from tightened muscles joint problems are corrected.

As noted above, much of the kinesiotaping method relies on proper placement and application of the tape, but doing so can be tricky. Furthermore, since its launch many competitors have released simi-lar tapes that mimic its properties. Using the original Kinesio Tape with the wave pattern on the adhesive side helps to keep it air per-meable. Then elasticity of the tape needs to be considered. When choosing a tape, it is suggested to use one with a stretch potential of 130 to 140 percent of its original length, as this mimics the human skin. Prior to applying, the correct length and shape of tape needs to be cut depending on the specific muscle group you are treating and size of the athlete or patient. Cuts may include “I”, “X”, “Y”, and “fan” shapes. When the tape is ready to be applied the skin needs to be clear of dirt, oils and lotion to maximize hold. If you are applying tape for relief and healing, the tape should be applied with no tension starting at the tendons and extending to the origin of the muscle. If you are applying the tape for support and full range of motion, the tape should be applied with light tension, starting from the origin of the muscle and extending toward the tendons. Once the tape is ap-plied where you want, rub the tape for a few seconds to activate the adhesive. So is Kinesiotaping something you want to incorporate into your treatment plan?Dr. Kase has books explaining his techniques from taping everything from the scalenes to the hallicusbrevis. The first book suggested is Illustrated Kinesio Taping (ISBN 10: 1880047241 / ISBN 13: 9781880047248 ) is for learning the taping and start-ing out. If you are more advance and already comfortable with the technique, you can use Kinesio Taping Perfect Manual (ISBN 10: 0972159061 / 0-9721590-6-1 /ISBN 13: 9780972159067). If you are not comfortable trying the technique yourself and would like to find resources to certified professionals, the Kinesiotaping website may be used to find local certified practitioners in your area at www.kine-siotaping.com. Many say they have had great results from this new technique, but remember it is the technique not the tape that yields the results! Sources•Crawford, Stephanie. “How Kinesio Tape Works.” 2011. (June 14, 2011) http://science.howstuffworks.com/kinesiology-tape2.htm•Kase, Kenzo, D.C. “Illustrated Kinesio Taping, Fourth Edition.” Ken’i Kai Information. 2005.•Kinesio. “Home.” KinesioTaping.com. Kinesio USA, LLC. (May 1, 2011)http://www.kinesiotaping.com/#

Kinesio Tape & Injur iesBy: Kristen Wilkey, MS, ATC, LAT, OTC

July 14th | Gwinnett Medical Center Athletic Trainer Boot Camp 2012

July 16th | Gwinnett Touchdown Club Annual Fellowship Golf Tournament sponsored by Sports Medicine South

July 28th | Gwinnett Football League Trainer’s Program hosted by Gwinnett Medical Center Doctor’s and Athletic Trainers

October 1st -31st | Physical Therapy Month

October 6th-12th | Physician Assistant Week

GHSA Championship ScheduleOctober 25th-27th | GHSA State Softball Championships

November 3rd & 5th | GHSA State Volleyball Championships

November 10th | GHSA Cross Country Championships

December 14th-15th | GHSA State Football Championships

Happening atWhat’s been

GMC...

photo compliments of http://www.kinesiologytapeinfo.com

Georgia Race for Autism

Annual Fellowship Golf Tournament

Annual Fellowship Golf Tournament

8 GSMM

A competitive basketball player comes to you complaining of problems with his ankle. His ankle is painful and weak due to repetitive sprains and exposure to high level sporting ac-tivity. He explains he wants to add support while playing without losing

motion and a natural feel. Which supportive method would be the best? Should you proceed with ankle taping or fit the athlete for an ankle brace? While the answer to this ques-tion may seem as though it should be simple, in reality, com-ing to the best solution is more complex. Numerous studies have suggested applying prophylactic taping and bracing will give benefit to athletes who have a previous history of ankle sprains. Prophylactic ankle taping has been considered a mainstay in competitive sports today and the athletic training realm. An alternative used today is ankle bracing. Although these studies have provided useful statistical data, there still remains much to still be discovered. Ankle sprains are one of the most common injuries in sports and occur almost seven times more than all other ankle in-juries. Most commonly, the anterior talofibular ligament is injured, followed by the calcaneofibular ligament. Previous misconceptions stated ankle sprains are caused by lateral movement. Conversely, most ankle sprains are caused by jumping and landing with an inverted plantar-flexed position. The high incidence rate of ankle sprains has led to increased prophylactic bracing and taping so much that it has become part of the uniform and a ritual many athletes will engage in before practice or games. Preventive taping and bracing are used to increase mechan-ical support and proprioception of the ankle. Proprioception is a conscious awareness of a body part position and move-ment. Proprioception is controlled by peripheral and central that come mostly from muscular receptors, but also includes cutaneous, articular and tendinous receptors. When an ankle injury occurs, all of these receptors are injured, with muscular receptors being affected the most. It is important to take all of these factors into consideration when treating and rehabilitat-ing a ankle injury.

The Art and Science of Ankle Taping vs. Bracing /// By: Eddie Knox III ATC, LAT

Ankle bracing and its concept evolved from ankle taping, and both methods have their respective benefits. Taping has been criticized for loosening during physical activity, allowing for more inversion of the ankle in which predisposesthe athlete to an ankle sprain. Also, it has been stated ankle taping will be of no support after approximately one hour of physical activity. Loosening occurs immediately, as soon as 10 minutes to 30 minutes after exercise, resulting to 40-50% of original support. An additional criticism of ankle taping, are the techniques used to tape the ankle. For example, one ath-letic trainer might tape the ankle differently than a coach, or another medical professional. Tension pull of the tape and direction of pull might be different due to individual’s ankle taping method. These differences can account and influence the ankle into more inversion than original literature has sug-gested. Cost and time of ankle taping are also big factors to consider. The cost of materials and use of time can be as-tounding with ankle taping. From experience and other stud-ies, the cost of ankle taping can be right around $1.75 per ankle depending on type and brand of tape. Taping at this price per ankle for one athlete would cost more than $400 dollars in one course of season. Although taping is good for incidental injuries, taping’s costly requirement, in conjunction with other factors of consideration, have lead health profes-sionals and other sporting teams to deem ankle bracing, both laced and Velcro Straps, a more viable choice to help protect their athletes. Ankle braces are self-applied, reliable, self-adjustable and cost effective in the long-run. Time savings with ankle bracing versus sport taping are also improved and allow the athletic trainer to provide more care, especially if the athletic trainer is working with a large number of athletes. Unlike sports taping, braces can quickly be reapplied and tightened. Ankle braces come in a range of styles from a simple lace up ankle brace, to semi-rigid ankle brace, and also a rigid ankle brace, which is mostly used with an acute ankle injury. Breathable mesh, Velcro straps, and semi-rigid inserts make ankle bracing safe and a great complement to ankle bracing. When choosing an ankle brace, it is important to pick or choose a reputable and quality brace. Many ankle braces on the market now, do not

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offer both stability and anatomical sup-port. Braces that act as sleeve with no straps or semi rigid inserts should not be used solely for the purpose of ankle stability and competition. Many brace types can be bought “off-the shelf”; however it can be quite confusing when choosing a ankle brace and determining which brace is right for you, patients, or athletes. Seeking professional medical advice or talking to you athletic trainer, is the best action to take, to ensure you are choosing a quality ankle brace for your sport and activity. To review, there are many disadvantag-es and advantages of both bracing and sports taping. Both ankle bracing and sports taping are well tolerated by ath-letes. Some athletes may prefer sports taping, because of the feel while others will choose ankle bracing. The cost ef-fectiveness of ankle bracing is important to consider and is more relevant in large number contexts. In a high school con-text, it may be a smarter investment to use ankle bracing due to large number of athletes and number of athletic trainers available. Currently, there has been no research that has concluded any clinical significance between ankle bracing and ankle taping. Yes, there have been slight statistical differences, but nothing confounding to confirm one technique is better than the other. The key is when choosing to use ankle bracing or ankle taping tailor the decision around your specific situation. In Division 1 programs, sports taping are a great option due to resources available versus a sec-ondary high school. Also, create and encourage an ankle

The Art and Science of Ankle Taping vs. Bracing <<<

injury preventative program for your athletes. This pro-gram should include strengthening, balance and stretch-ing exercises to help promote a healthy and strong ankle. Use of all resources will keep your athletes on the field and give the best chance to help reduce ankle injury.

Monday Tuesday Wed/Thurs FridayBack Squat Hip Mobility Deck Clean Hip MobilityUB Horizontal Pull UB Flexibility Vertical Push/Pull UB FlexibilityHang Clean Torso Stability Front Squat Torso MobilityBench Press Shouolder/Neck Trap Bar Deadlift Cuff & Grip

10 GSMM

To make things clear, there is NO perfect pro-gram. There is only the pro-gram that works best for your team, for the time you have to train, for the facilities and equipment you have, for the expertise you possess, and for the athletic skills of those

you are training. With that said, I wont simply give you an in-season program but instead show you the steps to develop an in-season program for the high school foot-ball player. From those steps, you will be able to design a program specific to your team and athlete’s needs. We have come a long way in the last decade and no longer is it a question of whether to train in-season but how best to train. In developing our training program, there were five specific questions that needed to be ad-dressed. I will walk through each question as it relates to my specific situation but remember it must be applied to your team and your athlete’s needs.

In-Season Football Strength & Conditioning Program <<<

Weekly Schedule:Saturday Sunday Monday Tuesday Wed/Thurs FridayInjury Clinic (if needed)

Film Review Workout #1 Recovery Workout #1

Workout #2 Recovery Workout #2

The recovery and regeneration days are vital to reducing physical and mental strain on the athletes as well as planning for specific corrective exercises to address areas of mobility and stability dysfunction. The following chart displays the exercise selection for the in-season athlete. The exercise selection will be dependent on training phase athletic skill set.

Monday Tuesday Wed/Thurs FridayBack Squat Hip Mobility Deck Clean Hip MobilityUB Horizontal Pull UB Flexibility Vertical Push/Pull UB FlexibilityHang Clean Torso Stability Front Squat Torso MobilityBench Press Shoulder/Neck Trap Bar Deadlift Cuff & Grip

2. Define what your goals are.Once the schedule is clear, you need to organize a sys-tem to best develop the athletes in the program. What are your program principles and philosophy? Do you want to maintain the level of strength and athleticism or continue to develop those skills? Do you focus on training or not overtraining? Do you prepare to play or to perform training exercises? Is it your goal to reduce the likelihood of injuries or to produce them? Of course those are rhetorical questions but must be de-fined and defended in order to qualify why you do what you do to coaches, parents and athletes. AT GACS, we wish to continually develop athleticism while reducing the likelihood of injury. We do this by monitoring the athlete for signs of overtraining and scheduling periods or recovery and regeneration. It is our goal that what we do in training will have a direct positive influence on the field play.

3. Create a plan to reach those goals.With the answers to the first three questions, it is now time to build a program for the football athlete and team. In order to continually develop our athletes, our in-season program maintains a high intensity work rate. The phases remain the same as do the percentage and the set-rep schemes. What does change is the number of heavy training days per week. The main exercises are consoli-dated into two days, Monday and Block Day (Block day is either a Wednesday or Thursday as we have a modified block schedule and see athletes on either day for four total days per week). The other two days are reserved for recovery and regeneration drills.

1. Define what “In-Season” means.The first question I had to answer was what is In-season and who is in it. At Greater Atlanta Christian School, we define the in-season athlete as “any varsity level player”.We believe in a long term athletic development plan and, therefore, junior varsity and freshman teams will generally participate in an off-season training program. This is done to maximize the athletic development of the individual. “Crossover” players that actively participate in both varsity and junior varsity team activities will be considered as an in-season athlete. Now that we are clear on who is in-season, we must decide when that specific period begins and ends. One of the first things I do every year is to create a yearly training schedule. This is often referred to as a macrocycle. The yearly macro-cycle is broken down into the two 18-week Fall and Spring Semesters. These smaller breakdowns are referred to as mesocycles. Finally, each mesocycle is broken down into monthly training cycles or phases. Each phase has a specific goal of physical development and builds on the foundation laid by the preceding period. The four phases we utilize are Hypertrophy, Maximal Strength, Conversion to Power, and Explosive Power. Each sport is then added to this schedule with in-season, post-season and off-season periods noted. To define the period of in-season training, each sport has its own time period of seasonal play allowed by the GHSA. Football begins its season on August 1st and continues until the second week of November. At that time a 5 week Post Season period begins culminating with the State Champion-ship in the Georgia Dome in mid December.

In-Season Football

Strength & Conditioning

Program Gary Schofield, Jr. ATC/L, CSCS, *D is entering his sev-enteenth year as a nationally certified and state licensed athletic trainer (NATA) and nationally certified strength & conditioning specialist (NSCA). Coach Schofield’s unique background of athletic training and strength and condition-ing has allowed him to coach and assist in the athletic de-velopment of athletes with teams and organizations such as the Atlanta Hawks (NBA), Georgia Force (Arena Football), Gwinnett Gladiators (ECHL), Atlanta Trojans (USBL), WCW Wrestling, Atlanta Silverbacks Pro Soccer (A-League), Georgia State Olympic Development Program, USA Track & Field Indoor Championships and many other pro and amateur organizations.Coach Schofield received a BS in Sports Medicine, with special emphasis in athletic training, from Marietta College (Ohio) in 1993. He continued his education with the gradu-ate program in athletic training at Georgia State University and is currently completing a Masters Degree in Education.

/// By: Gary Schofield, Jr. ATC/L, CSCS

GSMM 11

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4. Make sure you can do this!It’s great to have put together a solid program, but it is worthless if you can not follow it. At GACS, we have daily training classes that allow us the time to train each athlete. However, these classes are integrated with all male students grades 9-12 (we have female training classes as well). Therefore, the program needs to be flexible enough to train athletes that are in-season, post-season, off-sea-son, and pre-season. It must also allow for differ-entiation to address the training skills of each ath-lete from beginner to advanced athlete. To make this work, we train at the same intensity and percentage regardless of season preference. We have also manipulated the workouts so that the in-season workouts closely follow off-season in re-gards to the exercise selection. This allows both athletes to participate without conflicting equipment needs. For instance, In-Season Workout #1 con-sists of a squat variation, UB horizontal pull combo, hang clean, and a bench press while the Off-Sea-son Workout #1 follows the exact same selection

except that they perform torso stability exercises in-stead of the Bench Press. Again, by compressing the workouts into two days, it will allow two recovery focus days for the in-season athlete to work on areas of needed mobility and stability.

5. Produce Results.It should go without saying that any program must produce results or you will not be around long enough to continue using it. We constantly monitor our athlete’s production and response to the training program with a monthly “Performance Week”. Dur-ing this week we challenge both the in-season and off-season athlete to see where their max is in the Bench, Squat and Clean as well as lower body pow-er (vertical jump) and upper body power (medicine ball toss).A properly designed in-season program will allow the athlete to not only continue to develop strength, power and speed but remain injury free and capable of performing at the highest level on the field as well.

>>>In-Season Football Strength & Conditioning Program

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“The patient will see you now!”

Obstructive Sleep Ap-nea (OSA) is a medical disorder that is receiv-ing more attention be-cause of the growing presence throughout our population. It is es-timated that 30-50% of the population of the USA is affected.If there is:

1. Snoring with resuscitative “Snorts”2. Witnessed Spells by bed partner of interrupted breathing or breath holding3. Daytime sleepiness, difficulty staying awake while driving, or napping when getting home4. Neck collar size 17 inches or larger (90% chance of having sleep apnea) Then, it is advised to see a Primary Care Physician to schedule a sleep study. Here, the results can be reviewed with the patient and if abnormal, treatment options can be discussed, which will include: medical therapy, weight control, a trial of CPAP, oral appliance or surgery. Often, weight control is difficult because the OSA itself is accountable for the decrease in metabolism causing lowered oxygen concentrations while sleeping, burning off fewer calories, like cooking food over a low flame instead of a high flame. If this oxygen saturation can be raised by medical means or CPAP machine, then by getting the weight off with the patient feeling more energy and subse-quent cardiac exercise, symptoms can improve with the chances of higher oxygenation and improvement in the OSA symptoms. This will need to be individualized every time between the patient and his physician. For those who wish a more immediate result, the time hon-ored treatment is a CPAP machine, a nasal or face mask that is hooked to a compressor that provides continuous positive

pressure to force air through the nose or mouth and control the breathing process and eliminate or at least decrease the breath holding. This usually improves or eliminates the snoring as well. CPAP machines long term are about 47% successful as far as patient acceptance and compliance. Treatment with oral appli-ances for those with a recessed or weak chin can sometimes also be helpful by advancing the tongue and jaw forward, reported to be helpful in 8-10% of patients. Surgical correction is getting more attention due to increasingly successful and effective techniques, with reported results as high as 88% to nearly 100% ability to correct the three levels of ob-struction: nasal obstruction, oral obstruction and base of tongue enlargement and obstruction. The patients who select surgery do not approach this lightly, they are well versed ahead of time that it is an uncomfortable operation at the throat level and usually requires about two weeks for recovery and long term follow up for at least one year to monitor symptoms, weight, etc. Expected weight loss with the surgery alone can sometimes be as much as 10-20 pounds in the first 10 days.

/// By: Robert A. Gadlage MD FACS

Sleep Apnea and The Athlete:Treatment

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Level 2- MOUTH AND OROPHARYNX SURGERYThis includes enlarged tonsils and adenoids, enlarged or “floppy” uvula hanging down from the soft palate, which in time may also stretch out the soft palate and causing hang-ing down onto the tongue or collapsing onto the back of the throat in sleep.

There is another procedure just described in the last year known as Linguaplasty, which is done under local anesthesia as an outpatient in less than 30 minutes. The device can be adjusted as well as removed in the of-fice if not helpful. This is an exciting new procedure that should be available within the next year. The success rates in our practice with over 20 years experience and nearly 1000 patients operated on and followed up for at least one year, is that those who have had the Nasal and Oropharyngeal Surgery (Levels 1 and 2 above) at the same time, have reported a success rate of 88% not needing a CPAP machine since ALL symp-toms have been eliminated, and 78% report an inability to make a snoring noise after surgery. The 12% who don’t get complete resolution of their symptoms, or if their symptoms return at any time, get a repeat Sleep Study, and if Sleep Apnea is still present, then a CPAP trial would be recommended (many of who now can tolerate it since the obstruction of the nose and mouth have been eliminated) or Level 3 surgery as described above, which carries an additional 90% success rate in correcting Sleep Apnea. So, sleep apnea or OSA is not just a snoring problem. It indeed is a growing health problem for the general population and unfortunately, seen more frequently in the larger sized individuals such as athletes who require larger bulk for their profession. The good news is that recognition of OSA and treatment is more accepted to where the athlete can participate at the highest level possible without compromising unnecessarily physical attributes.

Sleep Apnea and The Athlete: Treatment <<<

Level 3- BASE OF THE TONGUE AND HYPOPHARYNX SURGERY (area between back of tongue and vocal cords)This includes surgical procedures which mobilize the tongue forward so it doesn’t collapse into the back of the throat and in-clude procedures such as Hyoid Suspen-sion, Genioglossus Advancement, Maxil-lo-mandibular Advancement, all of which are more involved surgeries and usually recommended after the level 1 and 2 sur-gical sites have been corrected or are not a contributing factor.

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The types of surgical correction are for the levels corrected:Level 1- NASAL SURGERYThis includes correcting any nasal obstruction whether it be a de-formed external nose from previous injury, or an internal obstruc-tion caused by a deviated nasal septum, nasal polyps or turbinate enlargement seen with allergies. This is best confirmed by an Ear, Nose and throat examination including a flexible office endoscopy and radiographic examination, which also checks for sinus disease.

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”Stingers” or “burners” are commonly seen in athletes, especially ones that are prone to contact injuries, such as football players, wrestlers, gymnasts and hockey players. They are due to nerve injury the results from trauma to the neck or shoulder. The brachial plexus is located in that region and is therefore susceptible to injury in the form of either di-rect pressure or traction. The athlete usually senses a burning or stinging phenomena that travels down the arm hence giving the name of the patho-logic process. Typically this is a very transient sensation and therefore also known as transient brachial plexus neuritis. The incidence of stingers is truly unknown. The reason is because most athletes tend to ignore it since the vast majority of cases are typically very transient in nature and only last a few seconds or minutes, although it can last hours or even days. Therefore, most cases go unreported. The cases that are reported, usually show a high risk of recurrence. This may also be due to the fact that the athlete continues to perform the same task that puts the plexus at risk. Despite the benign nature of the presentation, there could be potential dangerous long-term effects. Although the sensation may be transient, re-petitive trauma to the nerves can cause permanent damage. The location of the plexus is very superficial in the neck and shoulder region. Therefore it is very easy to be injured with direct trauma, as well as stretch if the head and arm are pulled in opposite directions. As one can also conclude, the upper trunk is usually the division that is most prone to injury. Its location is most superficial and therefore most prone to direct injury. Additionally, the upper trunk’s location requires the most excursion distance with any type of motion of the neck or arm in opposite directions, hence making it vulner-able to a traction type injury. Typically the athlete will complain of paresthesias or weakness in the affected arm. This is most commonly seen in the deltoid and rotator cuff muscles presenting with difficulty in shoulder motion. Occasionally, the ath-lete may also present with a limp arm. Typically the most response of the athlete is he will attempt to shake out the arm. Although, the upper trunk is most commonly injured, this injury is not isolated only to the upper trunk of the brachial plexus. It may affect any division of the brachial plexus, including more proximally at specific nerve roots that arise out of the cervical spine. The foreamen that the roots emerge from the cervical spine is usually protective in nature, but with any type of pre-existing foraminal stenosis or acquired stenosis from dy-namic ipsilateral bending of the cervical spine, it may become a form of entrapment and tether to the roots. This may in turn cause a direct compression type injury to nerve roots or tether it and prevent it from it’s normal motion and cause a traction type of injury. With a careful physical examination and knowledge of anatomy, a health care provider can at-tempt to identify the specific injury pattern. However, it is very difficult to perform especially since most of the cases are transient in nature.

The specific type of nerve injury can be of any grade. Fortunately, most injuries are only neuroprax-ias which are grade 1 injuries. This is a form of nerve function disruption by demyelinization. Axonal integrity is preserved, and remyelinization occurs with-in weeks. Grade 2 injuries, axo-notmesis, and grade 3 injuries, neurotmesis, are more devastat-ing, but luckily also rare. Treatment of this injury should be performed immediately at the timing of the occurrence. The first step is to take the athlete out

of action. Whether it be during practice or during a game, a side line physical exam should be per-formed immediately. Prior to any type of return to play, the player needs to be completely asymp-tomatic and back to baseline. Even if the player is asymptomatic, repetitive examination is of ut-most importance. It should be performed at the time of injury as well as at the end of the game or practice and a few days later. If the symptoms are prolonged, the athlete should be sent to a physi-cian for further evaluation. Although permanent injury is very rare, recurrence is not. Therefore evaluation and prevention is the key component of the treatment plan. The treatment of an acute injury showed consist of rest until asymptomatic or if needed physical therapy as well as range of motion exercises. The key to prevention is not only equipment protec-tion but more importantly education. The athlete should be advised on injury pattern and mecha-nisms to avoid it. Burners are typically benign. However, coaches, athletic trainers or any side line personnel should be vigilant of red flags. One of these that are very concerning would be if the athlete presents with bilateral symptoms or additional leg symptoms. This is a sign of a more dangerous injury involving the spinal cord itself and not just its roots. This can occur with either a very high impact collision on a normal athlete or low impact injury to an athlete who is congenitally predisposed to injury with spi-nal stenosis. Therefore these types of occurrenc-es should require immediate medical attention. To conclude, Burners and stingers are typically benign and transient in nature. However, the occurrences should be documented thoroughly with repetitive physical examinations. The ath-lete should be restricted from any physical activ-ity until his symptoms have completely resolved. Recurrences are very common and need to be assessed by a health care provider for further evaluation. Any signs of spinal cord injury need to be evaluated immediately by a physician since this could lead to permanent and devas-tating disabilities.

A Closer Look at Stingers and Burners/// By: Tuan Bui, MD IS PROUD TO SERVE

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While a low Torg ratio does not necessarily indicate a propensity for stingers, those who have sus-tained a stinger and have a low Torg ratio are more likely to sus-tain further stingers. On the other hand, the average Torg ratio is reported as 0.685 in the setting of an initial episode of cervical neu-ropraxia. Athletes who are allowed to return to contact sports following an initial episode of cervical neur-praxia have a higher likelihood of a second instance with a lower Torg ratio. In addition, the combination of cervical stenosis, straightening or reversal of the normal lordotic curvature of the cervical spine, and pre-existing minor radiographic evidence of prior bony or ligamen-tous cervical spine injury is termed

the “spear-tackler’s spine.” This spine configuration has been reported in previous athletes who have sustained permanent neurologic damage. While x-rays and Torg ratio calculations are useful as an initial screening tool, more advanced imaging—particularly cervical spine MRI—provides a more thor-ough evaluation. The soft tissue contrast of MRI is far superior to the limited bony detail that is able to be obtained from a screening cervical radiograph.

Imaging of Stingers <<<

With MRI, spinal stenosis can be esti-mated using the space around the cord (SAC), which is obtained by subtracting the diameter of the cervical cord from the diameter of the spinal canal. The amount of cerebrospinal fluid surrounding the cord and providing a cushion against spinal cord injury is a more accurate depiction of the degree of spinal stenosis, although normal standards for SAC values have not yet been developed. Additionally, MRI imaging provides a detailed evaluation of cervical injuries, including neural forami-nal stenosis, disc herniation, cervical cord contusion, ligamentous disruption, spinal cord masses, and fracture. Preventing permanent neurologic in-jury is of the upmost importance for the athletes, families, coaches, trainers, and physicians. The decision when and if an athlete should return to sports is multi-factorial, relying heavily on the patient’s symptoms and physical exam findings. Radiographic and MRI imaging of the cervical spine can play an important sup-plemental role in safely returning athletes to the field.

Sagittal T2 weighted MRI demonstrating central spinal stenosis with an average Torg ratio of 0.69 and an average SAC of 2 to 3mm. Note the disc herniations at C4-5, C5-6, and C6-7 compressing the central cord as well as the straightened appearance of the vertebral bodies with loss of normal lordosis.

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Transient brachial plexopathy, more commonly known as a stinger or a burner, is a common sports related injury often encountered in football and other impact sports. The trauma results in a temporary burning or weakness in the affected arm that usually lasts only minutes. Different mechanisms of injury have been suggested, including direct trauma to the brachial plexus, brachial plexus stretch injury, or cervical

nerve root compression at the neural foramina. The brachial plexus stretch injury involving depression of the affected shoulder and lateral neck flexion away from the side of impact is more commonly seen in young athletes. Cer-vical nerve root compression is related to neck extension and is more often associated with college or professional athletes. The paresis related to a brachial plexus injury should be unilateral and only involve an upper extremity. Sensory and/or motor symptoms involving all four extremities, both arms, both legs, or one arm and one leg are indicative of a different diagnosis termed cervical cord neuropraxia. This condition is considered more serious than the typically benign stinger. Cervical neuropraxia ranges from purely sensory to motor weakness to complete paralysis, with Grade 1 injuries lasting less than 15 minutes, Grade 2 injuries lasting 15 minutes to 24 hours, and Grade 3 injuries lasting greater than 24 hours. The mechanism of injury is suspected to be a forced exten-sion of the cervical spine resulting in shortening of the cervical spine, folding of the dura mater, thickening of the ligamentum flavum, and narrowing of the subarachnoid space. This combination results in decreased blood flow and/or increased pressure on the spinal cord. Radiologic evaluation for the typical transient stinger event is usually un-necessary. The decision to image is often based upon atypical symptoms, prolonged duration, or multiple recurrent episodes. However, any episode of cervical neuropraxia should have further imaging evaluation. Radiographs are useful as an initial screening tool to evaluate for bony central canal ste-nosis. The Torg ratio has been described in the literature as a method to standardize the evaluation for cervical canal stenosis on a lateral cervical spine radiograph. Magnification varies on radiographs depending on patient body size and technique. To compensate for this magnification, Torg and Pavlov proposed measuring the ratio of the vertebral body to the spinal ca-nal (See figure 1). The measurements were obtained at the C3, C4, C5, and C6 levels, and an average Torg ratio can be calculated. An average ratio of 0.8 or less was initially used as the cutoff for cervical stenosis. Later au-thors have proposed that an average ratio of 0.7 or less (almost 2 standard deviations below the normal value of 0.94) is a better predictor of functional spinal stenosis. However, limitations of the Torg ratio have been observed in certain populations, particularly professional football players, whose larger vertebral bodies overestimate the degree of stenosis.

Imaging of Stingers& Burners /// By: Lance Dasher, MD

Sagittal T2 weighted MRI in a normal spine with an average Torg ratio of 0.89 and an average SAC of 5mm.

Lateral view of the spine with Torg ratios measured C3-C6 with an average Torg ratio of 0.80.

All athletes want that competitive edge, something that will improve their performance and help them achieve their athletic goals. There is also tremendous pressure

to perform and to win at all costs. Many athletes choose to turn to supplements as the answer rather than to food itself. It is hard to open any kind of fitness magazine and not be bombarded with images of svelte athletes, pictures of big muscles and ad after ad for the newest pill or powder to promise all kinds of results from blasting fat to increasing muscle mass. What is considered a supplement? The legal definition of a sup-plement according to the Dietary Supplement Health and Educa-tion Act (DSHEA) of 1994 is anything taken orally, contains a “di-etary” ingredient such as an herb, vitamin, mineral or amino acid, is not meant to be a meal or meal replacement and is presented as a dietary supplement by the manufacturer (1). DSHEA pro-vided a legal definition and labeling guidelines for supplements but there are no other regulations governing supplements. Sup-plements are not tested for safety or effectiveness before being put on the market. In fact the FDA must prove that a supplement is unsafe before it can be removed from the marketplace. A recent article in the Chicago Tribune reported that almost half of the supplement manufacturers inspected by the FDA were found to have violated standard manufacturing practices (2). Furthermore, the FDA found in another report that weight loss and muscle-building supplements were highly likely to be con-taminated with banned substances, including stimulants (3). An athlete is responsible for everything he or she ingests, so not knowing that a supplement is contaminated is no excuse and can result in disqualification or worse yet, ban from the sport. Despite the dangers and warnings, adolescents are using supplements. In a recent survey, 70% of adolescents reported taking at least one dietary supplement (4). The most popu-lar supplements for football players are creatine and protein supplements. The American Academy of Pediatrics does not recommend for any child or adolescent to use dietary sup-plements for enhancing sports performance. The American College of Sports Medicine also does not advocate the use of dietary supplements and specifically states that creatine should not be used by anyone under the age of 18 due to the potential adverse health consequences and lack of research. Research has shown that creatine may be of benefit in short bouts of repeated high intensity exercise lasting less than 30 seconds and in improving performance of weightlifters when it is used at recommended doses (5). Again, creatine is not rec-ommended for anyone under the age of 18 as research has not been conducted to prove its safety. Research has also shown, however, that adolescent athletes often do not use supple-ments as recommended and creatine can be a gateway to other more harmful supplements like anabolic steroids (4, 6). If a person does want to take a supplement, there are some points that need to be considered and questions to ask regard-ing the quality, safety, cost and efficacy of the supplement. As stated earlier, there are no regulations in place to ensure that supplements are pure, safe or effective. First, what is the qual-ity of the ingredients being used in the supplement? Are these ingredients pure or is there a risk for contamination with harmful or banned substances? According to the Chicago Tribune article some manufacturers do not test their raw ingredients for purity or contamination before making their product (2). Is there a third

party reviewing and testing the supplement? Are the ingredients found in the supplement considered safe? Does the supplement contain banned substances by the NCAA? And finally, does the supplement do what it says it will do? At what risk? At what cost? These are all questions to be considered carefully before any supplementation begins. The supplement industry is a $28 billion industry and growing. The far-reaching promises made by some manufacturers and slick marketing campaigns only add to the pressure that some athletes feel that taking supplements is necessary. Often times it is not and should only be entered into after careful consideration and discussion with a medical professional such as a physician or a sports dietitian.To learn more about supplements visit one of the following websites:National Center for Drug Free Sport http://www.drugfreesport.com/index.asp United States Anti-Doping Agency http://www.usada.org/supplement411 National Collegiate Athletic Association ht tp : / /www.ncaa.org /wps/wcm/connect /pub l ic /NCAA/Health+and+Safety/Drug+Testing/Resources/NCAA+banned+drugs+list Natural Medicines Comprehensive Database http://naturaldatabase.therapeuticresearch.com National Institutes of Health Office of Dietary Supplements http://ods.od.nih.gov/HealthInformation/DS_WhatYouNeedToKnow.aspx

To find third parties who screen supplements visit one of the following websites:NSF Certified for Sport© http://www.nsf.org/business/athletic_banned_substances/in-dex.asp?program=AthleticBanSub Consumer Lab: http://www.consumerlab.com Informed Choice: http://www.informed-choice.org/ United States Pharmacopeial Convention: http://www.usp.org/ Banned Substances Control Group: http://www.bscg.org/ Food should come first. There is no pill or powder that can replace eating well. Supplements are just that, something to be taken as a supplement to the diet if key nutrients are lack-ing, not in place of it. Whole foods provide all the nutrients an athlete needs to perform at his or her best. Food is also more affordable than supplements, which are often expensive. In addition there is a synergistic effect of food that cannot be isolated into pill form. An athlete’s body should be treated like a fine sports car requiring the best fuel possible in order for it to perform as it was designed. For a competitive athlete, tak-ing a supplement without careful consideration, research and consultation with a qualified health professional is a gamble that is often not worth the risk. References U. S. Food and Drug Administration. Dietary Supplements Q&A. Available at: http://www.fda.gov/Food/Di-etarySupplements/ConsumerInformation/ucm191930.htm#what_is. Accessed September 4, 2012. Tsouderos T. Dietary Supplements: Manufacturing troubles widespread, FDA inspections show. Chicago Tribune. June 30, 2012. Available at: http://articles.chicagotribune.com/2012-06-30/news/ct-met-supple-ment-inspections-20120630_1_dietary-supplements-inspections-american-herbal-products-association.U. S. Food and Drug Administration. FDA Uncovers Additional Tainted Weight Loss Products. March 20, 2009. Available at: http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm149547.htm. Accessed July 16, 2012.Hoffman JR, Faigenbaum AD, Ratamess NA, Ross R, Kang J, Tenenbaum G. Nutritional supplementation and anabolic steroid use in adolescents. Med Sci Sports Exerc. 2008; 40(1):15-24.Dunford M, Coleman E. Ergogenic Aids, Dietary Supplements, and Exercise. In: Rosenbloom C, ed. Sports Nutrition: A Practice Manual for Professionals, 5th ed. Academy of Nutrition and Dietetics; 2012: 128-161.Nisevich Bede PM, Child and Adolescent Athletes. . In: Rosenbloom C, ed. Sports Nutrition: A Practice Manual for Professionals, 5th ed. Academy of Nutrition and Dietetics; 2012: 249-272.

To Supplement or Not to Supplement<<<

To Supplement or Not to Supplement?

www.dunawaydietetics.com

/// By: Ann Dunaway Teh, MS, RD, LD

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About 85% of sports-related concussions go unrecognized and untreated. Because of this, the Sports Medicine Program at Gwinnett Medical Center-Duluth is leading the way in concussion management by offering the Immediate Post-Concussion Testing (ImPACT) program to every high school athlete in Gwinnett.

As the only hospital in Georgia to offer ImPACT countywide, our goal is to reduce the chance of follow-up concussions, thus helping our student athletes’ performance both on the field and in the classroom.

To learn more about our program, visit gwinnettsportsmed.com.

Gwinnett Medical is a proud recipient of the 2012 Healthgrades® America’s 100 Best™ Hospitals

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